Provider Demographics
NPI:1619997798
Name:PETERSEN, STEVEN J JR (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:PETERSEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 PRESERVATION CIR
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-8340
Mailing Address - Country:US
Mailing Address - Phone:920-217-9708
Mailing Address - Fax:920-217-9708
Practice Address - Street 1:874 PRESERVATION CIR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-8340
Practice Address - Country:US
Practice Address - Phone:920-217-9708
Practice Address - Fax:920-217-9708
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45500207L00000X
SC40029207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34360900Medicaid
H82218Medicare UPIN
WI017807650Medicare ID - Type Unspecified